Healthcare Provider Details

I. General information

NPI: 1588141956
Provider Name (Legal Business Name): INFINITE COMMUNITY ACHIEVEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SHAKER DR STE 104
LEXINGTON KY
40504-3674
US

IV. Provider business mailing address

715 SHAKER DR STE 104
LEXINGTON KY
40504-3674
US

V. Phone/Fax

Practice location:
  • Phone: 704-524-3403
  • Fax:
Mailing address:
  • Phone: 859-313-9738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1144558701
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1144558701
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1144558701
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number1144558701
License Number StateKY

VIII. Authorized Official

Name: MR. RAZHEDE HIGHSMITH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 859-313-9738